Wednesday, 27 March 2013

Paper Prepared for the National Center for Health Care Technology
on the Social and Ethical Aspects of Transsexual Surgery
By Janice G. Raymond
Assistant Professor of Medical Ethics and Women's Studies
Hampshire College/University of Massachusetts
Amherst, Massachusetts
June, 1980

The subject of transsexualism, whether raised in the public forum or in the academic or medical communities, has been viewed generally as a medical issue that requires hormonal and surgicalintervention. Several assumptions accompany this profile of
transsexualism.

That the transsexual is a person who is trapped in the body of the wrong sex. Thus we have the popular definition of a transsexual as a "female mind in a male body."[1] This results in the perception of transsexualism as a disease or as disease-like and thus a medical problem. In many cases, a "cure" can only be effected through radical intervention such as specialized hormonal treatments and sex conversion surgery.

That it is possible to transsex, i.e., to change one's sex through such medical intervention.

That it is a therapeutic necessity and a reasonable and humane treatment to perform surgery on those individuals who have undergone rigorous preoperative psychological evaluations and who can truly "pass" as members of the opposite sex. Furthermore, proof
of the surgery's efficacy is that over 90% of those who have undergone transsexual operations report that their lives are healthier and happier.

The aim of this paper is to analyze these assumptions and, in so doing, to address the much-neglected social and ethical issues surrounding transsexual surgery. Transsexualism is an important medical ethical issue that raises questions that go far beyond the transsexual context -- questions of bodily mutilation and integrity, medical priorities, unnecessary surgery, the inevitable issue of the medical model in general, as well as definitions of maleness and femaleness, and the boundaries of such. Scholars will also find that transsexualism touches the parameters of many of the academic disciplines in such a way as to raise fundamental questions about the territorial imperatives of biology, psychology, medicine, and the law, to name but a few. Questions about the causes of transsexualism and the proper methods of treatment have been hitherto restricted to the domains of psychology and medicine. But as an ethicist, I would maintain that these issues of causation and treatment are often embedded with social values and philosophical beliefs -- values and beliefs about the so-called natures of womenand men, for example.
Historically, one could say that some people have always felt "trapped" in the wrong body, in the wrong skin, and in the wrong period of time. But this feeling never certified them as members of the "right" body, skin, or period of time. For example, persons who
felt "trapped" in black skin were never encouraged to undergo a
pigmentation change. Ultimately, it was recognized that such
"trapped" feelings were encouraged by a society that oppressed and
discriminated against black people, and that it was the society that
needed changing, not the individual black. In the same way, to
acknowledge that a man who feels trapped in his native-born body is
a transsexual (and ultimately, through hormonal and surgical
intervention, a woman), is to ignore the social causes and
ramifications that surround the issue. Indeed, one must ask why it
is possible in this society that persons could even talk about a
"female mind in a male body."
If transsexualism is a disease, then does desire qualify as
disease? As Thomas Szasz has asked, does the old person who wants
to be young suffer from the "disease" of being a "transchronological"
or does the poor person who wants to be rich suffer
from the "disease" of being a "transeconomical?"[2]
Transsexualism as disease raises many deeper issues about the
medical model in general and the ways in which transsexualism has
come to the defined as legitimate medical territory. Within the
last century, more and more areas of life have come to be defined as
medical and technical problems. This is most evident, of course, in
the mental health realm where all sorts of behaviors have been
categorized as diseases, and then treated by drugs, surgery, and
other medical-technical means. My point here is to affirm that more
and more personal, moral, and now social problems are defined as
medical problems when they are actually human and social conflicts.
Approaching these conflicts from a diagnostic and disease
perspective prevents the person who is dissatisfied with his sex
from seeing the issue in an alternative framework. Specifically,
persons who think they are transsexuals are not encouraged presently
to see this desire as arising from the social constraints of
masculine and feminine role-defined behavior. Thus a man who wishes
to be emotional or non-aggressive is encouraged to think of himself
as a woman instead of as a man who is trying to break out of the
masculine role.
The ultimate effect of defining transsexualism as a disease,
and as a medical problem, is to encourage persons to view other
persons (especially children) who do not live out proper and
appropriate sex role behavior as potential transsexuals. Thus, for
example, for the boy who likes to play with dolls or the girl who
wants to be a truck driver, these behaviors can be interpreted as
transsexual behavior instead of as non-stereotypical behavior that
helps to break down sex roles. Thus the classification of
transsexualism as a disease or as a therapeutic category relegates
non-stereotypical sex-role behavior to the medical realm.
It is important to understand that doctors here are not curing
a disease. They are actually engaged in the political and social
shaping of masculine and feminine behavior. Several facts bear out
this contention. Here especially, I note the role of the so-called
gender identity clinics and private therapists who foster and
reinforce stereotyped behavior. Persons wishing to change sex come
to these clinics or go to individual therapists to receive
counseling and ultimately to be referred for treatment and surgery.
It is a primary requirement of these centers that men who wish to be
transsexed must prove that they can "pass" as "true women" in order
to qualify for treatment and surgery. "Passing" requirements
evaluate everything from an individual's feminine dress, to feminine
body language, to so-called feminine positions in intercourse. Most
clinics require candidates for surgery to live out opposite
sex-roles and rigidly defined stereotypical behavior for periods of
six months to two years. Thus the role of these clinics and
clinicians in reinforcing sex-role stereotypes is significant and,
as I have tried to show above, one that has consequences that reach
far beyond the transsexual issue. I would suggest that what we are
witnessing here is a "benevolent" form of behavior control and
modification. It is not inconceivable that gender clinics, in the
name of therapy, could become potential centers of sex-role control
for non-transsexuals--e.g. children whose parents have strong ideas
about the kind of masculine or feminine children they want their
offspring to be.
The ultimate effect of viewing the desire to live as a member
of the opposite sex as a disease or as a medical category is that a
social and ethical issue becomes transformed into a therapeutic and
medical-technical problem to be solved by "passing" requirements,
hormone therapy, and sex conversion surgery. Medicine focuses on
the surgical construction of desired genitalia. Artifacts of
silicone breasts, artificial vaginas, and the like come to incarnate
the essence of femaleness which the transsexual so desperately
desires.[3] Since the general result of sex conversion surgery is
that the transsexual becomes an agreeable participant in a society
which encourages conformity to rigid sex role behavior, then
ultimately the medical solution becomes a "social tranquilizer."
Sexism, and its foundation of sex-role stereotyping, is reinforced.
Transsexual surgery also enables doctors to gain medical
knowledge about the manipulation of human sexuality that probably
could not be acquired by any other medical procedures. In what
other medical situation could a penectomy be done upon a healthy
penis and an artificial vagina inserted into a chromosomal male?
What we also witness in the transsexual context is a number of
medical specialties combining to create transsexuals -- urologists,
gynecologists, endocrinologists, plastic surgeons, and the like.
The proliferation of treatments that has been generated to take care
of the "disease" is remarkable. These range from the initial and
basic operative procedures undergone by all transsexuals to highly
specialized forms of secondary cosmetic surgery such as eye, nose,
and chin operations.[4] Not coincidentally, hormone therapy and
surgery are expensive.[5]
The terminology of transsexualism becomes an issue in this
context. For by its very existence, the word perpetuates the notion
that transsexualism is a state of being, and that there is a group
of people who will continue to need the surgery because they are
"born" transsexuals. Until the surgery was popularized, in the
aftermath of the Christine Jorgensen case, the specific need of
surgery for a group of persons known as transsexuals was not evident
(although, of course, some people may have felt that they wished to
change sex). The extent to which the popularization and
availability of surgery has generated a wider need for it is
obscured by the terminology of transsexualism itself.
Finally, treating transsexualism as a disease and making it
medical territory have also masked the fact that a unique group of
medical consumers has been created by medicine itself. The
terminology of transsexualism disguises the reality that
transsexuals prove they are "real" transsexuals by conforming to the
canons of a medical institution that evaluates them on the basis of
their being able to pass as stereotypically masculine or feminine,
and that ultimately grants surgery on this basis. Once sex-role
dissatisfaction is given the name of transsexualism,
institutionalized in gender identity clinics, and treated by hormone
therapy and surgery, the category of transsexualism functions to
explain and order very valid dissatisfactions with sex-role
stereotypes.
The terminology of transsexualism raises the inevitable
question of is it possible to change sex, i.e., to transsex? To
answer this, it is necessary to discuss various meanings of the word
SEX, a word that has both a dismaying multiplicity and ambiguity of
meanings. John Money has distinguished various definitional levels
of the word SEX that are helpful in assessing whether it is
biologically possible to cross sex.[6] Chromosomal sex determines
biological maleness or femaleness, contrary to popular opinion that
anatomical sex is determinative. Normal males have a chromosomal
pattern of XY with normal females being XX. There are some
individuals who are born with chromosomal anomalies in which surgery
is often used to bring the anomalous person in line with the
anatomical characteristics that become most dominant, or else the
developing anatomical characteristics are altered in line with the
sex in which the child has been reared. The pattern of sex
chromosomes is present and unchangeable in every body cell,
including blood cells. Chromosomal sex can, however, conflict with
anatomical sex.
Anatomical sex refers to primary and secondary sex
characteristics. Primary characteristics include the testes in the
male and the ovaries in the female. Secondary anatomical sex
characters include the penis, scrotum, prostate, hair distribution,
and a deeper voice in the male; and the clitoris, vulva, uterus,
vagina, breasts, a wide pelvis, female voice, and hair distribution
in the female. Transsexual surgery alters anatomical sex through
hormonal and operative procedures.
Genital or Gonadal sex is the collective term for the tests in
the male or the ovaries in the female.
Legal sex is designated most often by genital sex, although
this is not actually defined in the codes. It is in this area that
errors of sex do occur, since the obstetrician or mid-wife may be
deceived by the apparent genital sex.
Endocrine or Hormonal sex is determined by androgen in the
male and estrogen in the female, supplied by not only the sex glands,
but also by the pituitary or adrenal glands. Endocrine sex is mixed to
certain extents since, for example, the testes as well as male adrenals,
produce certain amounts of estrogen.
Psychological sex or the word gender are terms used in much of
the literature to designate attitudes, traits, characteristics, and behavior
that are said to accompany biological maleness or femaleness. I would
prefer the term psychosocial sex to indicate the all-important factor
that
such attitudes, traits, characteristics, and behavior are socially influence
and orchestrated.
Historical sex is a term that I would add to this already lengthy
list of distinctions. History is important, in this context, because
there
is a certain constellation of events that attend the sex into which one
is born. For example, menstruation for a girl is a biological happening,
but it is also a historical event around which cluster a certain set of
very different yet also very similar collective female experiences. Men
do not have a history of menstruation nor the experiences which surround
its onset, its monthly occurrence, or its demise.
What significance does this delineation of the various
terminologies of sex have in answering the question of is it possible
to change sex? Beginning in order with the list of sex distinctions, the
most important reality is that it is biologically impossible to change
chromosomal sex. If chromosomal sex is taken as the bottom line of
maleness or femaleness, the male who undergoes sex conversion surgery
is NOT female.
Anatomically, transsexualism does take place, but anatomical
changes also happen in what is commonly termed plastic surgery.
Transsexual surgery alters genital or gonadal sex most intrinsically.
For example, it is possible to remove a woman's ovaries or a man's testes
through this surgery, and it is also possible to construct an artificial
vagina in a man whose penis and testes have been removed. The
question then becomes how much value one would give to this kind of
alteration in terms of changing the totality of a person's sex. George
Burou, a Casablancan physician who has operated on over 700
American men who wanted to become women, expressed the
superficiality of changing genital sex in this way: "I don't change men
into women. I transform male genitals into genitals that have a female
aspect. All the rest is in the patient's mind."[7] Furthermore, a change
in genital sex does not make reproduction possible.
Endocrine or hormonal sex is the most susceptible to alteration,
but this is done without surgical intervention. Hormonal intake of
opposite-sex hormones have certain anatomical effects resulting in, for
example, breast for men or a redistribution of body hair for both
women and men. Hormonal treatments must be lifelong, however, for
most of the anatomical effects to be prolonged.
In law, it is possible to transsex; that is, it is possible to change
one's legal sex. However, the whole area of legal sex has been one of
contention for the transsexual who wishes to have sex conversion
surgery validated by a corresponding change of sex on official papers
such as birth certificates, social security, drivers' licenses, and the
like.
If it is impossible to change basic chromosomal structure, then
it is necessary to take a more in-depth look at not only the terminology
but also the reality of transsexualism? Can we call a person a
transsexual, biologically speaking, whose anatomical structure and
hormonal balance have changed, but who is still genetically XY and
XX? If chromosomal sex is not the bottom line, what are we really
talking about when we say that a person is a biological male or female?
Is there any such enduring reality as biological maleness or femaleness?
Obviously, there is more to maleness or femaleness than
chromosomal make-up. Feminists have been arguing this for years, and
I am not re-affirming the biology is destiny argument. In fact, it is
transsexuals and defenders of the surgery who are asserting a new form
of biology is destiny. For what they are ultimately saying is that it
is impossible to change male or female behavior, traits, characteristics,
and the like UNLESS one also changes one's body. Transsexuals define
themselves by exclusive reference to the body of the sex they want to
be. This is a new variation on the theme of biology is destiny. What
transsexuals and those who support the surgery affirm is that persons
are irrevocably determined by what body they are born with. In the
transsexual context, persons desiring the surgery become enfettered by
both the unwanted body of their chromosomal sex (which they reject)
and the body of the opposite sex for which they are willing to undergo
painful and mutilating surgery. Ultimately, the transsexual and the
medical community which supports surgery give the message that the
body is all-important, that it does guide one's destiny, and that all
else is body-bound.
Chromosomal sex is the enduring reality which determines
biological maleness or femaleness. This can never change. What is
more significant in determining the totality of maleness or
femaleness, however, is what I have called historical sex. No man
can have the history of being born and located in any culture as a
woman. He can have the history of wishing to be a woman and of
acting like a woman, but this is the history of one who DESIRES to
be a woman, not of one who is a woman. Surgery may confer the
artifacts of outer and inner female organs, but it cannot confer the
history of being born a woman in this society.[8]
History, of course, is not static. All of us make changes in both
our personal and social history. I am not advocating that history should
determine the boundaries, life, and location of the self. However, there
are aspects of anyone's personal and social history that cannot be
changed. For example, a person who is born into a particular class
cannot change that history. He can change his class attitudes, habits,
and complex of behaviors that accompany a certain class typology.
Likewise, in the transsexual context, a man cannot change his history
of having grown up male. Men who want to change masculine attitudes,
habits, and complex of behaviors should not take on the bodies of
women but rather should try to change their unwanted history in their
own bodies.
To summarize, it is impossible to change sex, i.e., to transsex,
because it is impossible to change not only the chromosomes of one's
native-born sex but also much of the personal and social history that
accompanies biological maleness and femaleness.
Proponents of transsexual surgery claim that the only way of
treating those individuals who find themselves to be born into "the
wrong sex," and who have undergone rigorous preoperative screening
procedures, is ultimately through sex conversion surgery. It is
emphasized that many persons who think they might be candidates for
surgery are weeded out through these stringent evaluations, and only
those who can truly "pass" as women (or men) are referred for surgery.
For this small number of individuals, transsexual surgery is not only
a therapeutic necessity but a reasonable and humane treatment.
Furthermore, the majority of postoperative reports of transsexuals
testify that the surgery has been proven effective and efficacious and
is therefore no longer experimental. They cite the fact that 90% of those
persons who have undergone surgery report that their lives are happier
and healthier.[9]
These reports, however, do not explore the deeper social issues,
nor do they question a satisfaction that is achieved at the expense of
never investigating the underlying social and ethical issues. They do
not state that after surgery the transsexual fits into a role-defined
world better than most native-born women who live out their feminine roles.
Critics of this position maintain that it would be an
overwhelming burden on both the transsexual and the therapist to
attack so large a problem as sex-role socialization in the therapeutic,
never mind social, context. Therefore, it is easier, to confront the
problem within role limits, making use of a ready-made social structure
that created transsexualism initially. While proponents of transsexual
surgery may admit that it would be preferable to modify society's
attitudes toward masculine and feminine behavior, they emphasize that
in the immediacy of the therapeutic moment, the task of social change
is impossible. Faced with the personal crisis of a gender-disturbed
individual, they opt for ignoring or relegating the social effects to
a secondary place.
However, in the name of dealing with an individual crisis, it is
important to note that this kind of therapy does not foster genuine
individualism. Current transsexual therapy and surgery promote an
individualism that serves a role-defined society. Thus, it is more
accurate to say that these are solutions that promote the values of
social conformity.
To use another example: Many oppressed people use heroin to
make life tolerable in intolerable conditions. Heroin usage is a highly
effective yet dangerous treatment for dissatisfaction and despair.
Recently, black leaders have drawn attention to heroin as a pacifier of
black people. The contentment and euphoria produced by the drug
diffuses the critical consciousness of the users.
Although there are many real differences between the users of
heroin and the recipients of transsexual surgery, the analogy is
appropriate in at least one significant way. Transsexual surgery
produces satisfaction and relief for the transsexual at the expense of
muting his or her critical consciousness of the ways in which such
surgery reinforces sex role behavior. Thus transsexuals are not
encouraged to ask how their own socialization conditioned not only
their choice of surgery, but also their motivation to choose.
It is in this sense that transsexual surgery can be said to be
experimental surgery. Transsexuals are seeking surgery to relieve
gender discomfort and dissatisfaction. Within the context of a roledefined
society, the surgery is narrowly successful at doing this for
some
transsexuals. But there is no evidence to prove that the surgery "cures"
the deeper problems which lead many persons to seek the surgery. In
other words, sex conversion surgery cannot bestow upon the transsexual
the sense of self that he or she lacks. Furthermore, there is evidence,
at least in some postoperative cases, that transsexuals themselves have
come to realize this, but too late. Meyer and Hoopes, as early as 1974,
noted that a group of their patients had reacted self-destructively after
surgery. These reactions included multiple and serious suicide attempts,
drug abuse, and serious physical complications.[10] Randall in an
earlier study, reported on four cases (out of 29) in which postoperative
adjustment was worse than before the operation. The behavior
included suicide, suicidal impulse, moral depravity, and a wish to reverse
the effects of the operation.[11]
One of the first well-known physicians to work in the areas was
Charles Ihlenfeld, an endocrinologist, who was a co-worker and protege
of Harry Benjamin. Ihlenfeld left the field after helping one hundred
or more transsexuals change sex because as he reported to have said:
"Whatever surgery did, it did not fulfill a basic yearning for something
that is difficult to define. This goes along with the idea that we are
trying to treat superficially something that is much deeper."[12]
Finally, Johns Hopkins terminated transsexual surgery in 1979
after conducting a study of fifty transsexuals which showed that there
was no significant difference in successful life adjustment between those
who underwent transsexual surgery and those who did not. The study
was the first to compare postoperative transsexuals with an unoperated
group of persons who wanted the surgery. The study, initially reported
in the ARCHIVES OF GENERAL PSYCHIATRY and in the press
release issued by Johns Hopkins which appeared in newspapers across
the country said, among other things: "Physicians have to ask themselves
if transsexual surgery is medically necessary. To say that this type
of surgery cures psychiatric disturbance is incorrect. We now have
objective evidence that there is no real difference in the transsexual's
adjustment to life in terms of jobs, educational attainment, marital
adjustment, and social stability."
On physical grounds alone, there is a substantial amount of
evidence to confirm that sex conversion surgery is experimental.
Transsexual treatment is far from established as a safe medical
procedure. In some instances, it has been known to cause cancer. In
1968, W. Symmers reported two cases of carcinoma of the breast in
which the transsexuals died. He suggested that the malignance was
entirely due to the hormonal imbalance created by castration plus the
massive does of estrogen received.[13] There are several other studies
that have investigated the correlation between male-to=constructed
female transsexualism and cancer.[14]
This paper has argued that the issue of transsexualism is an
ethical one that has profound social and moral ramifications.
Transsexualism itself is a deeply moral question rather than a medicaltechnical
answer. In concluding, I would list some suggestions for
change that address the more social and ethical arguments I have raised
in the preceding pages.
While there are many who feel that morality must be built into
law, I believe that the elimination of transsexualism is not best achieved
by legislation prohibiting transsexual treatment and surgery but rather
by legislation that limits it and by other legislation that lessens the
support given to sex-role stereotyping, which generated the problem to
begin with. Any legislation should be aimed at the social conditions
that initiate and promote the surgery as well as the growth of the
medical-institutional complex that translates these stereotypes into flesh
and blood. More generally, the education of children is one case in
point here. Images of sex roles continue to be reinforced, at public
expense, in school textbooks. Children learn to role play at an early
age.
Nonsexist counseling is another direction for change that should
be explored. The kind of counseling to "pass" successfully as masculine
or feminine that now reigns in gender identity clinics only reinforces
the problem of transsexualism. It does nothing to develop critical
awareness, and makes transsexuals dependent upon medical-technical
solutions. What I am advocating is a counseling that explores the social
origins of the transsexual problem and the consequences of the medicaltechnical
solution. It would raise questions such as the following: is
individual gender suffering relieved at the price of role conformity and
the perpetuation of role stereotypes on a social level? In changing sex,
does the transsexual encourage a sexist society whose continued
existence depends upon the perpetuation of these roles and
stereotypes? These and similar questions are seldom raised in
transsexual therapy at present.
I am not so naive as to think that these measures would make
transsexualism disappear overnight, but they would at least pose the
existence of a real alternative to be explored and tried. Given
encouragement to cultural definitions of both masculinity and
femininity, persons considering transsexual surgery might not find it
as necessary to resort to sex conversion surgery.
Public education must also be emphasized. Up to this point, the
transsexual and the transsexual professionals have been the sources of
information for the general public. The mere existence of the
postoperative transsexual, moreover, and the fact of the surgery's
availability permit people to restrict their thinking about sex role
dissatisfaction to these medical-surgical boundaries.
One way in which education about transsexualism has reached
the general public is through the media. Famous transsexual
personages such as Jan Morris or Renee Richards appear in widely
circulated magazines and on television talk shows. Thus transsexualism
becomes "media-ized" in certain prejudicial ways, which contribute to
public opinion that surgery is indeed the solution to gender
dissatisfaction. Different perspectives on the issues of transsexualism
need to receive more attention and publicity. We need to hear more
from those men and women who, at one time, thought they might be
transsexuals but decided differently -- persons who successfully
overcame their gender crises without resorting to medicine and surgery.
We need to hear more also from professionals such as endocrinologist
Charles Ihlenfeld who, after helping many to change sex, left the field.
Finally, we need to listen to persons, such as feminists, who have
experienced sex role dissatisfaction but did not become transsexuals.
In the final analysis, it is important to remember that
transsexualism is merely one of the most obvious forms of gender
dissatisfaction and sex-role playing in a role-defined society. It is
one of the most obvious because, in the transsexual situation, we have the
stereotypes on stage, so to speak, for all to see and examine in an alien
context. What can be overlooked, however, is that these same
stereotypical behaviors are lived out every day in "native" bodies. The
issues that this paper has highlighted should by no means be confined
to the transsexual context. Rather they should be confronted in the
"normal" society that spawned the problem of transsexualism to begin
with.
Footnotes

Since the preponderance of those seeking the surgery and those
undergoing it are men, my consistent references throughout this
paper are male pronouns and examples. According to
international medical literature, only one out of four persons
who requests and obtains surgery is female. I also use male
references, because I do not want to contribute to a false
affirmative action mentality which represents transsexualism as
a human problem. It is very clearly a male phenomenon.

See Thomas Szasz, review of THE TRANSSEXUAL EMPIRE:
THE MAKING OF THE SHE-MALE by Janice G. Raymond,
New York Times Book Review, June 10, 1979, p. 11.

The medical literature on transsexualism is a good example of
the way in which the medical model has confined the questions
raised by this issue to a narrow and fetishized field of inquiry.
Such literature is replete with photographs, plates, and
anatomical drawings of sexual organs. Interestingly, these
photographs seldom show the whole person. They center on
the genitalia. The narrow area of the chemical and surgical
specialties commands attention here in such a way that the
primary problem often is represented as how to construct a
vagina, for example, in an aesthetic a way as possible.

A "salvation by surgery" ethic is created by the initial transsexual
procedures. Secondary operations are often sought by the
transsexual, usually for esthetic reasons and/or to correct real
or psychologically felt complications. This cosmetic surgery
frequently has nothing to do with refashioning the genitalia.
Rather such surgery is undertaken in the hope of conforming
the postoperative body more to fashionable and stereotypical
feminine body images. Many transsexuals resort to an immense
amount of polysurgery to fit themselves to the prescribed body
measurements and gestalt of a curvaceous feminine figure.

1978 figures estimated that, on the average, the male-toconstructed
female operation and hospital stay alone can cost
from $3,000 to $6,000. The female-to constructed male
operation involves a series of several operations before the
results are achieved and costs up to $12,000. There are, of
course, many other expenses besides the surgery and hospital
bills.

See John Money, "Sex Reassignment as Related to
Hermaphroditism and Transsexualism," in Richard Green and
John Money, eds., Transsexualism and Sex Reassignment
(Baltimore: Johns Hopkins University Press, pp. 91-93 (1969).

For this reason, I use the term "male-to-constructed female" to
indicate that only a superficial change does take place, that
while transsexuals are stereotypically feminine, they are not
fundamentally female, and that it is impossible to change sex.
Thus transsexuals do not convert from male to female but from
male-to-constructed female.

What of persons born with ambiguous sex organs or
chromosomal anomalies that place them in a biologically
intersexual situation? It must be noted that practically all of
them are altered shortly after birth to become anatomically male
or female and are reared in accordance with the societal gender
identity and role that accompanies their bodies. Persons whose
sexual ambiguity is discovered later are altered in the direction
of what their gender rearing has been (masculine or feminine)
up to that point. Thus those who are altered shortly after birth
have the history of being practically born as male or female and
those who are altered later in life have their body surgically
conformed to their history. When and if they do undergo
surgical change, they do not become the opposite sex after a
long history of functioning and being treated differently.

Percentages vary slightly but most authors doing postoperative
follow-up report that "the majority of" or "most of" the
transsexuals they surveyed are satisfied, both with the results
of the surgery and with their own state of being after the
operation.

W. Symmers, "Carcinoma of the Breast in Transsexual
Individuals after Surgical and Hormonal Interference with
Primary and Secondary Sex Characteristics," British Medical
Journal, 2 (1968):83. Symmers reported on two cases of
transsexuals who came to autopsy with carcinoma of the breast.

J. Hoenig et al., in their article, "The Surgical Treatment for
Transsexuals" (Acta Psychiatra Scandinavia, 47 [May 1974]:106-
36), state that surgical treatment to increase breasts in male
transsexuals should not be undertaken, especially if such
treatment is followed up with estrogen therapy, since there is a
risk of malignancy. Other studies that have investigated the
correlation between male-to-constructed-female transsexualism
and cancer are:
The Veteran's Administration Cooperative Urological Research
Group "Treatment and Survival of Patients with Carcinoma of
the Prostate, Surgery, Gynecology, and Obstetrics, 124
(1967):1011.

D. Bailar and D. P. Byar, "The Veteran's Administration Cooperative
Urological Research Group: Estrogen Treatment for
Cancer of the Prostate: Early Results with Three Doses of
Diethylstilbestrol and Placebo," Cancer, 26 (1970):257.

SOURCE: National Center for Health Care Technology
Division of Medical and Scientific Evaluation
5600 Fishers Lane
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As the result of this paper, existing governmental policy was changed so that it

effectively eliminated federal and some states aid for indigent and imprisoned transsexuals. It had a further impact on private health insurance which followed the federal government's lead in disallowing services to transsexual patients for any treatment remotely related to being transsexual, including breast cancer or genital cancer, as that was deemed to be a consequence of treatment for transsexuality.

I'll be writing a post in future discussing the numerous factual inaccuracies, omission of significant details, "spin" and other Academic sins that bedevil this paper, along with scientific findings made since this paper was written that debunk it. Those the author cannot be blamed for, unless it's for the sin of hubris, asserting as fact what is conjectured, without sufficient disclaimers. Something I have to watch in myself when writing for a popular audience, though not in Academic papers. There, Good Science and Academic Honesty demands sufficient room for doubt, while in a popular context, may cloud the issue and inevitably lead to misinterpretation.
I will include some other words from the author, in her book "The Transsexual Empire". A work where she makes no attempt to hide her real agenda.

"All transsexuals rape women’s bodies by reducing the real female form to an artifact, and appropriating this body for themselves. "

The transsexually constructed lesbian-feminist feeds off woman’s true energy source, i.e. her woman-identified self. It is he who recognises that if female spirit, mind, creativity and sexuality exist anywhere in a powerful way it is here, among lesbian-feminists

I contend that the problem with transsexualism would best be served by morally mandating it out of existence

That is, an XX woman can end up with an XY body, even her ovaries. Anatomy is everything, chromosomes irrelevant.

Now one can define sex as purely chromosomal; or depending on height,
as “men are taller than women” so everyone above average height is *by
definition* male, or anything else. Hair colour. Length of fingers.
Whatever. Some definitions make more sense than others. No single metric
is accurate enough to be sufficiently useful. Base it on reproductive
capacity, and many will be of neither sex, and a handful of both.

Sex in that sense is socially constructed, though based on objective
biological facts. Which facts are chosen though, that varies.

This whole ideology is based on a false premise. “The Earth is Flat, therefore…..”

As for the idea that Transsexuality is a social construct about gender performance, with no biological component:

And so on and so on. The facts don’t support this notion, no matter
how ideologically comforting it may be. Again, no matter how strong
your religious or ideological commitment, no matter how damaging you may
think the notion is to your beliefs about what is right or just; no
matter how much you may think that the notion, if widely held, would
destroy society and cause misery and chaos – the evidence is that the
Earth is not Flat.

More trenchant commentary on this, and scans of the document, at ENDABlog.

A PRIMARY school teacher who began the new term as a woman, has died.
The news of Lucy Meadows' death was announced to pupils and staff at St Mary Magdalen's School, in Accrington, this week.
The school wrote to parents last Christmas to inform them that Nathan Upton would be returning as a woman after Christmas.
Pupils had been asked to address the teacher as Miss Meadows from the start of the Spring term.

Headteacher Karen Hardman said staff will be working with bereavement teams and the school will be offering support to children.
She said: “News of Lucy's death has come as a tremendous shock to everyone in the school. She was a greatly valued member of our staff and we send her family and friends our sympathy and prayers.
“We are working closely with the county council and the diocese to ensure we offer our pupils and staff the support they need.
“I would ask people to respect the privacy of everyone involved at this difficult time.”

From the hit piece in the Daily Mail:

The school shouldn’t be allowed to elevate its ‘commitment to diversity and equality’ above its duty of care to its pupils and their parents.
It should be protecting pupils from some of the more, er, challenging realities of adult life, not forcing them down their throats.

Shouldn't they feel proud of what they've accomplished, instead of trying to hide it? A good job of hiding reality from children? After all, having a revered teacher hounded to death is far less harmful to young minds than the teacher changing sex.

Conclusions After 10 years of randomised treatment, women receiving hormone replacement therapy early after menopause had a significantly reduced risk of mortality, heart failure, or myocardial infarction, without any apparent increase in risk of cancer, venous thromboembolism, or stroke.

They used bio-identicals you see, not cheaper, artificial estrogen-like compounds as with other studies.

Cemeteries can be pretty bleak places, but when it is on the outskirts of a faceless Dutch suburb under a grey January sky, it feel about as about as desolate as you can possibly get. When you are visiting the grave of a child who killed herself in her early teens, the feeling of despair, especially when accompanied by her mother, gives way to an urge to weep bitterly. It is an urge which I am unable to resist as I do the maths subtracting the date of death from the day she was born. It is one thing to be told Juliaantje* was only 14, but to see it carved in marble was too much to bear. Holding her photograph her mother sobs uncontrollably as I hug her while she in turn hugs a precious photograph.

The picture is of a sunny, smiling, apparently bubbly teenager, with long hair and a grey T-shirt. There is nothing in the picture to suggest that she was transgender, but that is the reason she took her life.

When she was 12 her mother tried to have her put onto hormone blockers to delay puberty. She didn’t want to develop body hair, a deep voice or have wet dreams. She had already self-harmed when young, trying to slice her penis off with a pair of scissors. However, in what was clearly a borderline decision, the psychologists decided to that she should not be given these drugs. She should be given counselling instead. In despair her mother, a single parent, tried to take her to the United States, but the air fare and the £200 a month cost of these drugs was way beyond her means. Her father had no money either and both sets of grandparents didn’t want to know.

Two years later the talking therapy failed. Juliaantje took a massive overdose and died, having self-harmed, abused alcohol and other substances for more than a year before that.

“She was an intelligent and lively girl.” Her mother tells me through the tears and a large glass of Genever in a nearby café, probably the only thing that can deaden the pain of losing her only child. “She had a great future ahead of her, she could have done anything, been a doctor, a lawyer her teachers said…” Her voice breaks. Her happy nature had disappeared when male puberty really hit. “Her voice broke and she started to get facial hair and hair on her chest. She wore make up and turtle-neck jumpers to hide it all, but she simply couldn’t deal with the way her body was developing…”

Did she blame the psychiatrists? No. Psychiatry is never going to be an exact science, there will always be people who don’t fit into their categories. She does however, feel that they could have given her the benefit of the doubt. “The effects of hormone blockers are easy to reverse, you just stop taking them…” There would have been no risk to her daughter if, at any time she decided that she did not want to be a girl she could simply have stopped, and male puberty would have started.

Hormone Blockers are essentially a way for young trans people and children to leave their options open. They open an extended open window of choice, which gives them time to think about their future, a time during which young people can decide whether they wish to remain the sex they were assigned at birth, whether that be male or female, or whether they need gender reassignment surgery after the age of 18. Talking to mothers of transgender children in the UK who have been prescribed hormone blockers, usually at great cost (£200 a month plus the cost of a consultation in and flight to the United States) one thing comes across loudly and clearly; “I would rather have a live daughter than a dead son.” One of them told me. One mother had remortgaged her house to pay the cost of these drugs knowing what her child was like, she realised that this would probably be the only way to keep her alive.

Another mother talked of how her young child had been prescribed a cocktail of a dozen drugs, including Ritalin, because of behaviour problems at home and at school. Yet when her child was recognised as transgender everything changed. As soon as she was treated as a girl, the tantrums, the bedwetting, the crying, the screaming, the hyperactivity, the violence, just stopped, as did the need for any of the drugs. “She became happy and contented almost overnight, just because we treated her like a girl! The psychologist who spotted this probably saved her life.”

Predictably the accusation of “child abuse” has been levelled at those who advocate prescribing hormone blockers to children between the ages of 12 and 15 (they already are prescribed to those over the age of 16) in the UK. This flies in the face of the evidence in both the United States and Holland, where these drugs have been successfully, and harmlessly prescribed for many years. It also flies in the face of the experience of parents of transgender children, who have lived a day-to-day existence, hoping that their child is still alive and in one piece. Until her daughter was prescribed hormone blockers at age 16 one mother told me of the anguish she and her husband felt when their child had gone missing for a few days when she was 14. “We really thought we would never see her again. Every time the phone rang we thought it would be the police wanting us to identify a body.”

Now that this technology has been developed, not making it available to all those children who need it is child abuse. Three years ago the trans community was shocked by the suicide of a transgender child who was only 10 years old. The allegation of “child abuse” has been levelled at parents who permit their transgender child to express the gender they prefer and who let them have hormone blockers. Yet this is effectively child abuse in reverse. Not to allow trans children to express their gender identities is actually child abuse. Those who throw accusations of child abuse around without knowing the facts are the ones who are child abusers by proxy; putting pressure on parents to force their children to conform to the gender they were assigned at birth no matter what the consequences

About Me

Actually, I am a Rocket Scientist.
Also hormonally odd (my blood has 46xy chromosomes anyway) and for most of my life, I looked male, and lived as one, trying to be the best Man a Gal could be. Anyway, in May 2005 that started changing naturally for reasons still unclear, and I'm now Zoe, not Alan : happier and more relaxed not to have to pretend any more.
UPDATE - reason now identified as the 3BHSD form of CAH.

Reviews

This blog, written by a rocket scientist, is a fascinating collection of information, both personal and scientific, regarding intersex, transsexualism and related psychosocial and psychosexual issues....It is erudite and heartfelt. Just read the posts about the passport issue. You won't know whether to laugh, weep or crawl into a ball and rock gently in a corner - an amazing person.- David---The reason I so appreciate bright, perceptive people - as opposed to ideologues whose intelligence does little to illuminate - is that they manage to both instruct and learn with a certain grace. Among such rarities in the transblogosphere is Zoe, whose direct speech and clear humanity always make her worth reading, even if one doesn’t always agree with her every conclusion.- Val---The following is a request for permission to archive your A.E.Brain blog site which we have wanted to do for several years...The Library has traditionally collected items in print, but it is also committed to preserving electronic publications of lasting cultural value....Since (1996) we have been identifying online publications and archiving those that we consider have national significance....We would like to include A.E.Brain blog site in the PANDORA Archive...-Australian National Library